A site about recovering from a stroke

A Therapist’s Job

Rebecca wrote a blog post in response to one of mine, so I’m writing another blog post in response to her response. I talked about patients not doing their prescribed exercises at home, which is called non-compliance in the therapy world. I commented on her blog post this…..”It’s all about wanting to feel better and taking personal responsibility for your health. And sometimes that involves hard work that isn’t much fun and that you don’t want to do.” She replied something about a therapists job being to make the exercise more meaningful to the patient or something. I highly disagree with that. That is soooo not a therapist’s job. A therapist’s job is to tell you what to do in order to make you feel better. Then it’s up to you to do it. It’s about taking personal responsibility for your health. A therapist’s responsibility is not to modify an exercise to make it more fun and meaningful. Modifying an exercise is PART of a therapist’s job when necessary, but it’s not our main job at all. And modifying a functional activity is a totally different thing. It is our job to provide a thorough explanation of why these exercises are being prescribed then again, it’s up to each individual patient to decide for themselves if the prescribed exercises will be helpful and up to each individual patient to do them at home. If you’re not thoroughly explaining the exercises and making the patient understand why they’re meaningful, THEN you have not done your job. If I’ve learned anything from this experience, it’s that if I want to get better, it’s up to ME. I have to take responsibility for myself and do the hard work even and especially when it sucks.

21 replies

Zack’s OT likes to give him “fun” therapy. She usually does this for his fine motor control and skills. She will have him play different games where he has to put small items into holes to try and use those precise movements and also he’s having to pinch which is really hard for him. But I honestly think he hates it. It’s not fun for him at all. He’s a really good sport about it, and who knows, maybe he would rather do a game than some other less entertaining form of exercise. I think it’s mostly annoying to him because these are things that he used to be super good at, so even though it’s a game, he still doesn’t have as much fun As he would have before.

Zpater, I have the same problem for 4 years, so I have worked on using and strengthening my peronius muscles (try everting your foot while you lie in bed at night, and try tapping your toes whenever you listen to music). I’m sure Amy and Rebecca have professional suggestions for exercises. Plus, I ended up getting a Bioness L300 to stabilize my ankle and prevent foot drop while I walk; that does the trick, but is very expensive.

Amy & Rebecca, you are both right. As a multi therapy patient, I say that I am more apt to do therapy that is fun, in my best interest, shown benefit of such a program AND with a therapist who is willing to make it interesting enough to continue.

You are not a failure as a therapist. Some patients just will not be motivated to do home exercises. I’m motivated but run into difficulty when the exercise needs more than me to do daily. I expect my therapists to figure a way that I can do the exercises without help or help me figure out a way to do it. I don’t expect too much . Not all will but the few that do have me and the rest of my family as a repeat customer.

Brooke- I gather Zack is a child. When my daughter was in therapy and had daily stretches twice a day (some painful), I made up rhymes and songs to do the exercises to. She was more apt to do them.

Zpatzer- I currently have an inverted foot. After a year, we are still working on it. Just keep at the exercises. The ankle/foot/toes just like the wrist/hand/fingers is often the last to come back if ever. It can take years because of smaller muscles and tendons.

Yeah, here’s the thing. That lady I think is in her 60s and I’m 32, single, no kids, etc. We are writing from 2 wildly, wildly, WILDLY different perspectives. It’s apples and oranges. When dealing with kids or someone with cognitive issues – it should go without saying that those cases need to be handled much differently.

Amy, yes, I agree that every patient needs to be handled differently. When I told my aquatic therapist that I wanted to do a “first” on my 4-year anniversary, she suggested water-walking a particular distance (half mile). I told her I wanted to tread water w/o flotation. She shook her head and told me that would be too hard. After a couple more sessions with me, she modified her reply to my insistence that I tread water to “we can try.” I think she realized her goal for me would have to differ from what she would help someone else toward. I think there are a lot of patients she wouldn’t have given in to. She had no choice but to modify her exercises for me.

Perhaps non-compliant patients need some creative suggestions about how they can fit in their exercises. For example, I don’t sleep well, so when I wake up during the night, I do exercises that are designed to be done lying on my back – stretching my pectoral muscles, everting my foot, etc. Although a PT might not consider that part of the job, if it helps increase compliance, more progress will be made, and both the patient and PT will feel more successful. I have an OT who often asks what activity I do, say, 100 times per day. I think of one in that ballpark, and she tells me that every time I do that thing, I should also do a particular exercise. For example, there’s a stretch I do every time I walk through a doorway in my house. I don’t actually manage to do it EVERY time, but I don’t consider myself non-compliant.

“She had no choice but to modify her exercises for me.” It doesn’t sound like she modified an exercise, it sounds like she attempted an exercise that at first she wasn’t willing to try. Modifying an exercise is PART of a therapist’s job when necessary, but it’s not our main job at all.

You’re right, Amy, she didn’t modify the EXERCISES, she modified WHICH exercises she has me do, and added ones that would help me keep my torso square when I was vertical (and could do lying down in bed, one of my favorite places to exercise), in place of a tuck-and-roll-forward/back that helps me propel myself through the water. What she and my OT have done is break down a goal and identify the skills I need, then give me exercises to help me regain those skills. I suppose all of you PT’s do that.

I agree with you Amy. I saw a ton of non-compliant patients in rehab and it just baffled me. I was pissed that their insurance just kept on paying for them to do nothing on their own, while I saw huge gains, worked crazy hard and they threw me out. The patient needs to take accountability and make sure the exercises they are doing will help them cross over to important tasks in their real life. I think its the patient’s job to make it personal. All my goals, exercises were to help me get back to being a mom. Getting my arm strong enough to lift a 30lb. wiggley child was a huge feat, but wildly important to me. Ditto for every other exercise I had to do.

Elizabeth, last week in OT, I met a landscaper who was being pressured by workers’ comp to get back to work. When the OT asked him why he evaluated himself as being at only 70% recovered, he said that he was able to weed-whack for only 5 minutes. The OT pointed out that his doctor’s order had specifically told him NOT to weed-whack, and he said he had to be able to do it for at least 15 minutes to go back to his job. The OT insisted that he was not supposed to even TRY weed-wacking until ok’d for it. I said, “Let me guess, you’re one of those patients who is told, ‘don’t do this,’ and then puts that at the top of your to-do list.” He nodded. I have a friend who recently had a knee replacement, with post-stroke exercises assigned, and when I asked his wife how he was doing, she said, “Well, you know John – if he’s supposed to do 10 exercises an hour, he does 100.” We, the aggressively non-compliant patients, exist. It’s how we have lived our lives, and we’re not going to change now. Unambitious people exist too, have strokes, and are also unlikely to change.

Its probably those patients that are trying to get out of the box that their doctors have put them into. That going outside the box means the doctor has to actually expend some intellectual capital learning something new.

Yep Barb,
I agree. As perplexing as it was to me, the “lazy” people were probably like that their whole lives. Just seems when you are all messed up, don’t you get a wake up call that motivates you? Don’t they want to get back to their lives? There’s only one way to get better and its not sitting on your hands waiting. Nobody else can do it for you. Glad I was in your “aggressively noncompliant group” instead, chances at a good recovery have to be better if you are actually doing the exercises. They always made it clear to me that doing more sessions was a more productive way to “over do it” than simply more repetitions in a session, so that’s what I did…..and thankfully saw great results!

Hey Barb,
I sort of resemble that remark of being “aggressively noncompliant.” lol While I may not do the 100, I may push for another set. Like those machines that measure how hard your working, unless I’m told otherwise, I’ll set limits of where I want to be at and hold it there , and raise the level everyday I’m in therapy by 5 as a goal. I’ll tell my therapist is plan first and run it by them to see if it’s acceptable. If they tell me no, I’ll ask why and if makes sense like “because this is the optimum range and endurance you should be at” I’ll let it alone…I’m a compliant/noncompliant patient. Meanwhile at home I continued the same pace that was set by therapy.

I always asked first if I thought I could do more or wanted more of a challenge.

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Disclaimer…

This blog IS NOT intended to be medical advice of any sort. I am writing about my experiences, my knowledge, and my opinions. My goal is to tell people what I'm going through and hopefully help someone.
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All that being said, rest assured that everything you read on this blog is written by a highly educated, highly trained, and highly experienced medical practitioner.
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Dr. Amy Elder (formerly Shissler) PT, DPT, Cert. MDT------my full name and title